水中治療膝蓋、髖關節置換術的時機


  【24drs.com】根據線上發表於12月21日身體醫學&復健學誌的隨機控制試驗,全膝關節置換術(TKA)後6天開始水中治療者,與術後14天開始治療者相比,病患表示可改善結果;相對的,全髖關節置換術(THA)者等到術後14天開始治療者效果比較好。
  
  德國Schleswig-Holstein大學醫學中心骨科Thoralf R. Liebs醫師等人寫道,雖然治療差異未達統計上的顯著意義,TKA後及早水中治療的效果與非類固醇抗發炎藥物治療膝骨關節炎的效果相當。
  
  水中治療對THA和TKA復健有幫助,因為它讓病患在一個減輕體重負擔的環境運動,而可以逐漸恢復肌肉強度。病患一般會到術後14天才開始水中治療,主要是等傷口癒合。不過,Liebs醫師等人假設,如果病患及早開始治療可以改善臨床結果。
  
  為了評估TKA或THA之後進行水中治療的時機,研究者隨機指派進行THA (n = 280)或TKA (n = 185)的病患在術後6或14天進行水中治療。
  
  病患包括156名男性和309名女性、各項特徵在研究開始時相似,治療包括每週3次的30分鐘課程、直到術後第5週;水池運動目的在改善本體感覺、協調性和強度;在術後第3、6、12和24個月評估體能、疼痛度和僵硬度。
  
  主要結果為自我報告的體能改善程度,根據的是西安大略與麥梅斯特大學骨性關節炎指標(WOMAC),將結果和之前公告的最小臨床改善閾值進行比較,次級結果包括Medical Outcomes Study 36-Item Short-Form Health Survey、Lequesne-Hip/Knee-Score、WOMAC疼痛與僵硬分數以及病患滿意度。
  
  雖然追蹤期間整體研究對象並未達統計上的顯著差異,個別分析TKA和THA病患顯示,提早治療對兩組產生不同的結果;比較提早治療之TKA病患和第14天開始治療之TKA病患的各項WOMAC指標;WOMAC量表的體能效果範圍從0.22-0.39。
  
  THA病患中,延後治療者有比較好的結果,WOMAC效果範圍為0.01-0.19,不過,這些差異未達統計上的顯著程度。
  
  作者們寫道,這篇隨機研究顯示,對於THA和TKA,術後提早進行水中治療產生對健康相關生活品質的結果正好相反。
  
  TKA之後,提早水中治療可改善病患的臨床結果。另一方面,研究結果指出,髖關節置換術後,應避免提早水中治療。
  
  作者們推測,TKA病患提早水中治療獲得較大改善的解釋之一是,相較於髖關節病患術後,TKA病患術後的滿意度一般較低。
  
  作者們解釋,我們假設,THA之後提早水中治療時機的效果較差,是因為已達最大手術效果,病患滿意度比率較高,因THA的健康相關生活品質改善也多,因此,其他介入方式的改善空間自然有限。
  
  另一方面,TKA之後,不滿意的病患數顯著較多,使得其他介入方式較有改善空間。
  
  他們指出,另一個解釋則是膝關節和髖關節的生理差異。
  
  我們假設,除了已知的水中治療優勢之外,水中的流體力學降低了膝關節手術部位的積液。因為關節囊在TKA術後關閉,積液減少會減少疼痛抑制,因而導致功能恢復上的優勢,而關節囊在THA並未關閉,這個機轉並不適用於THA。
  
  作者們結論指出,需要更多研究來更加瞭解這個議題。
  
  資料來源:http://www.24drs.com/professional/list/content.asp?x_idno=6691&x_classno=0&x_chkdelpoint=Y
  

Timing of Aquatic Therapy for Knee, Hip Arthroplasty Matters

By Nancy A. Melville
Medscape Medical News

December 22, 2011 — Initiating aquatic therapy just 6 days after total knee arthroplasty (TKA) improved patient-reported outcomes compared with starting therapy 14 days after surgery, according to a randomized controlled study published online December 21 in the Archives of Physical Medicine & Rehabilitation. In contrast, waiting until day 14 to start aquatic therapy was better for patients who had total hip arthroplasty (THA).

"Although the treatment differences did not achieve statistical significance, the effect size for early aquatic therapy after TKA had the same magnitude as the effect size of nonsteroidal anti-inflammatory drugs in the treatment of osteoarthritis of the knee," write study authors Thoralf R. Liebs, MD, from the Department of Orthopaedic Surgery, University of Schleswig-Holstein Medical Center, Kiel, Germany, and colleagues.

Aquatic therapy is useful for THA and TKA rehabilitation because it allows patients to exercise in an environment that relieves body weight while muscular strength is gradually restored. Patients do not usually start aquatic therapy until 14 days after surgery, to allow the wound to heal. However, Dr. Liebs and colleagues and colleagues hypothesized that the clinical outcome could be improved if patients started therapy sooner.

To evaluate the effect of the timing of aquatic therapy after TKA or THA, the researchers randomly assigned patients undergoing primary THA (n = 280) or TKA (n = 185) to begin the therapy either 6 or 14 days after the surgery.

The patients included 156 men and 309 women with similar baseline characteristics. The therapy included 30-minute sessions given 3 times a week, up to the fifth postoperative week, for all patients. Pool exercises were designed to improve proprioception, coordination, and strengthening. Physical function, pain, and stiffness were evaluated 3, 6, 12, and 24 months after the surgery.

The primary outcome was self-reported improvement in physical function according to the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the results were compared with previously published thresholds for minimal clinically important improvements. The secondary outcomes included the Medical Outcomes Study 36-Item Short-Form Health Survey, Lequesne-Hip/Knee-Score, WOMAC pain and stiffness scores, and patient satisfaction.

Although there were no statistically significant differences in the total study population at follow-up, separate analyses of the TKA and THA patients showed early therapy had opposite effects in the 2 groups. All WOMAC subscales improved with early therapy in TKA patients compared with in TKA patients who started therapy at day 14. The effect sizes for physical function WOMAC subscales ranged from .22 to .39.

Among the THA patients, the later-therapy group had better outcomes, with WOMAC effects ranging from .01 to .19. However, those differences were not statistically significant.

"This randomized study showed that the use of early aquatic therapy has opposite effects in terms of health-related quality of life after THA when compared with TKA," the authors write.

"After TKA, early aquatic therapy led to clinically important improved patient outcomes when compared with late aquatic therapy. After hip arthroplasty, on the other hand, the results of this study indicate that early aquatic therapy should be avoided."

The authors speculate that one important explanation for the greater improvement with early aquatic therapy for TKA patients is a lower level of satisfaction that TKA patients typically have after the procedure compared with hip patients.

"We hypothesize that the weak effect of the timing of aquatic therapy after THA is due to the ceiling effect of that procedure, with a high rate of patient satisfaction and improvement of health-related quality of life due to THA alone, thereby leaving only a limited space for improvement by additional interventions," the authors explain.

"After TKA, on the other hand, a significant higher number of patients is not satisfied, leaving room for the effect of additional interventions."

Another explanation could involve the physiology of the knee joint vs the hip, they add.

"We assume that, apart from the known advantages of aquatic therapy, the hydrostatic force of water immersion reduces effusion of the operated knee joint. Because the joint capsule is closed after TKA, the reduction of effusion leads to less pain inhibition, and leading to an advantage in functional recovery. As the joint capsule is not closed during THA, this mechanism does not apply to THA."

Additional studies are needed to better understand the issue, the authors conclude.

The authors have disclosed no relevant financial relationships.

Arch Phys Med Rehab. Published online December 21, 2011.

    
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